Published in the March 2008 issue of Today’s Hospitalist
UNTIL FOUR YEARS AGO, Beth Israel Deaconess Medical Center in Boston used senior residents to supervise housestaff doing procedures. While that wasn’t unusual “hospitals across the country use senior residents in a similar capacity ” it made many of the hospitalists uneasy.
“I vividly remember doing a lumbar puncture as an intern and having real variability in how skilled my teacher was,” says Joseph Li, MD, director of the hospitalist program at Beth Israel Deaconess. “The senior resident may have done only one or two.”
Not only was the competence of the senior residents all over the map, Dr. Li says, but resources were being wasted. Interns were grabbing three or four kits to do a procedure, instead of just one, and housestaff often put off procedures until later in the day, potentially putting patients at risk.
“We were very concerned about what we didn’t know,” Dr. Li says about using senior residents as supervisors.
Beth Israel Deaconess came up with a new approach: It put hospitalists in charge of supervising all housestaff doing procedures.
In the several years since the hospitalists stepped in, both procedure performance and education have improved, largely because housestaff now have access to skilled teachers. “As the hospitalist, I’m there to limit the number of sticks,” Dr. Li says. “When housestaff don’t get feedback, it makes it more difficult for them to improve “or they end up improving at the expense of the patient.”
Resource utilization at Beth Israel Deaconess has gone down, and so have complication rates. And supervising hospitalists now have a better relationship with housestaff.
“Now that they don’t think of themselves as doing it alone,” says Dr. Li, who is also an assistant professor of medicine at Harvard Medical School, “housestaff are much more comfortable doing procedures.”
Standardizing the process
Bedside procedures such as paracentesis, lumbar punctures and arthrocentesis are scheduled by housestaff using a central system, with one hospitalist assuming the role of supervisor each day. (Most, but not all, of the 25 hospitalists in Dr. Li’s group have taken on the rotating role.) Because there’s a universal-pager system and a single number for the on-call hospitalist, Dr. Li explains, housestaff don’t have to “hunt down a schedule to see who’s on that day.”
The fact that housestaff have to schedule a hospitalist supervisor forces them to address the need for a procedure earlier in the day. Dr. Li says that also makes them think through the process of performing a procedure more carefully.
“Did they get consent to do the procedure, or do they need a translator to obtain consent?” Dr Li points out. “Does bloodwork need to be done to make sure patients don’t have an anticoagulation disorder before we stick them with a big needle?”
Launching the dedicated service also forced the hospitalists to think through another issue: how to standardize supplies.
Floors would stock different types of procedure kits, in part because providers developed clear preferences for one kit over another.
“They’d grab one, open it up and trash it if it wasn’t the kit they wanted to use,” Dr. Li says. “It dawned on us that we needed some consensus, that it was a waste of money to buy so many kits from different manufacturers.” The result was a hospital-wide agreement on what kit to stock on all floors.
Streamlining supplies for procedures produced other benefits. “There are some safety features built into newer kits that help prevent needle sticks,” he says.
Pushback and politics
Only a handful of teaching institutions have followed Beth Israel Deaconess’ lead, Dr. Li maintains, because it’s difficult politically to initiate such a departure from tradition. When the supervised service first started, certain hospitalists and housestaff members complained.
“There was pushback from some hospitalists who didn’t want to supervise because they thought it was faster to do the procedure themselves,” he recalls. “They were concerned about their own productivity.”
Some residents, on the other hand, weren’t pleased with the proposed arrangement because they thought being supervised would reduce their autonomy.
“Some welcomed it with open arms,” Dr. Li says, “but there were maverick types who just didn’t want the oversight.”
Then there were political undercurrents with other attendings, including hospitalists with other groups in the hospital or primary care physicians.
Even attendings who never did procedures, for instance, found Dr. Li’s name on a patient’s chart to be jarring at first. "All of a sudden, they think, ‘What are they doing seeing my patient? Is this the beginning of them trying to take my patient?’ ” he says.
Or an attending would order a procedure, which Dr. Li would then cancel when he showed up to supervise. “Here I am with a patient and the procedures specialist saying, ‘I’m not doing this procedure because I don’t think you need it,’ ” he says. “That’s a situation that you have to handle carefully.”
Revenue can be another potential barrier, he points out, because supervising residents takes time. “We could make more money just seeing patients without procedures.”
However, “we believe we are providing higher quality care in our hospital,” he adds. “This is part of our responsibility as teachers, and we receive support for our educational role.”
While the level of expertise that hospitalists bring to supervision is clearly higher than that of senior residents, Dr. Li says that hospital medicine has a long way to go to establish competency levels in performing procedures.
One avenue to explore, he adds, is how many hip replacements, for instance, surgeons must perform under supervision before they’re deemed competent enough to do one on their own. While he and his colleagues have begun to look at how many procedures housestaff have to perform before they feel comfortable doing them, establishing competency levels is beyond the scope of one hospital.
“This is something that has to be done on a much larger scale at multiple institutions,” he states, “before we can begin to think about telling someone, ‘You have to do this many procedures before you’re competent.’ ”
One thing is clear, however: More hospitalist groups concerned about quality are going to be considering procedures, particularly if they have doctors who are interested in performing them.
“There is a quality mandate now in terms of procedures,” Dr. Li says, pointing to catheter-associated bloodstream infections, a complication that Medicare may decide not to pay treatment costs for. “Many of these infections can be related to the placement and care of the catheter.”
Institutions that have high-volume proceduralists will be turning to those physicians to minimize the risk of infections. “It will be worth a lot of money,” Dr. Li says, “and it will be a metric that we’re looking at in every institution.”
Bonnie Darves is a freelance writer specializing in health care. She is based in Lake Oswego, Ore.